From Confusion to Clarity: New Mammogram Guidelines Explained!

Last week, the federal government released re-adjusted guidelines on breast cancer screenings, including mammograms and self-examination.

The new guidelines state that instead of receiving yearly mammograms beginning at age 40, women can now wait until 50 years old to begin the annual screenings. But the new recommendations set off a firestorm of frustration from particular groups like the American Cancer Society and caused confusion as well. There are claims that these new guidelines will put women in greater danger, particularly African-American women, who have the highest rate of death from breast cancer and are more likely to develop breast cancer before age 40.

The guidelines are clearly controversial with the debate focusing on whether or not breast cancer screenings at an earlier age are statistically helpful, whether the risk of exposure to radiation and the chances of false-positives and misdiagnoses are great enough to warrant this change or why the many women’s lives who have been saved by early detection and early screenings are not reason enough to keep the guidelines status quo.

So, what’s a woman to do?

Our Bodies, Our Blogs does an excellent job at breaking down the new guidelines: what they mean, why there were re-adjusted and how a woman can evaluate what’s best for her given the new landscape.

Cupaiulo confirms that far from disempowering women to take care of their health, these new guidelines align with the World Health Organization’s recommendations, and may help women to have a clearer understanding of the health impact of mammograms:

I don’t believe the new guidelines are politically motivated, nor are they “patronizing”
to women simply because they call into question the stress related to
biopsies and false positive results. Rather, the guidelines provide a
useful framework for helping each of us to decide when is the best time
to begin screenings and the intervals at which they should be repeated.

The guidelines are in sync with international recommendations; the World Health Organization
recommends starting screening at age 50, and in Europe, mammograms are
given to post-menopausal women every other year and detection rates are
similar to the United States. During an interview on MSNBC
on Tuesday, breast cancer expert Dr. Susan Love said the government’s
guidelines bring us into line with the rest of the world and with
current research. (Read more at her blog.)

In response to the claims that these new guidelines will ultimately affect insurance coverage for mammograms, Cupaiulo quotes a New York Times recent article which, in part, explains:

The guidelines are not expected to have an immediate effect on
insurance coverage but should make health plans less likely to
aggressively prompt women in their 40s to have mammograms and older
women to have the test annually.

But, here’s the thing. Cupaiulo is careful to note that there is no reason why women should not be encouraged to continue to make their own decisions they feel are right and best for their health and lives.

If you’re reading this and thinking you still want to keep that scheduled mammogram, you should certainly do so.

“No one is saying that women should not be screened in their 40s,” said Petitti, the task force vice chair. [Ed. note: of the advisory group that released the new guidelines] “We’re saying there needs to be a discussion between women and their doctors.”

Dr. Amy Abernethy of the Duke Comprehensive Cancer Center said she agrees with updated recommendations.

Dr. Petitti also wanted to clarify that the new recommendations did
not tell women to stop doing breast self-exams, just like they did not
tell women not to have mammograms until age 50. Rather, the advisory
group recommends against routine mammography in younger women.

“Nothing in our recommendations says that a woman who finds a lump shouldn’t go to her physician,” Dr. Petitti said.

For some women for whom the anxiety of false-positives, exposure to radiation over a span of years or opening themselves up to surgery to remove a lump that may never have been harmful in the first place, these recommendations may elicit a sigh of relief. But for many others, the personal experience of losing someone close to breast cancer or receiving a diagnosis of breast cancer via a mammogram at an early age, these new guidelines don’t feel right.

Many years ago, the National Cancer Institute tried to convince everyone not to screen women younger than 50 but were given such a tongue lashing by Congress that they went home, licking their wounds and withdrew their recommendation. Likewise, the American Cancer Society (ACS) avoids looking clearly at the data and continues to recommend screening for women under fifty. The ACS doesn’t want to enrage its donor base and Congress didn’t want to upset constituents and breast cancer specialists have faith in the procedure. Dr. Otis Brawley, the cancer society’s chief medical officer, was quoted in the New York Times admitting "that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated." This is the same view he expressed at a cancer symposium in Milan back in 2003. Following the task force report’s release, however, Brawley changed direction, telling the Times that the cancer society had concluded that the benefits of annual mammograms beginning at 40 "outweighed the risks" and that the ACS was sticking by its earlier advice. One of Brawley’s colleagues said, "He’s trying to save his job. He was broiled at home for the interview in which he said that the medical establishment was ‘overselling’ screening." And Health and Human Services Secretary Kathleen Sebelius told American women that they have nothing to learn from the science that led to the USPSTF guidelines on mammography. I guess the President didn’t want to upset his constituents. We would like to believe that medical advice we get is based solely on good medical practice and evidence-based medicine. It is important to note that companies like General Electric and DuPont, both which manufacture mammography equipment, are large donors to organizations, such as the American Cancer Society, that are aginst any change in the recommendations. The US Preventive Services Task Force (USPSTF) is not the US government or a panel of government officials. The task force is made up of independent primary care doctors and others whose stated interests include decision modeling and evaluation, effectiveness in clinical preventive medicine, clinical epidemiology, and the prevention of high-risk behaviors. Research by the Nordic Cochrane Centre in Denmark raised questions about the effectiveness of mammography. In a study of 2000 women, they found that one woman would have her life prolonged but 10 would undergo unnecessary treatment and 200 women would experience unnecessary anxiety because of false positive results. According to the authors of the study, it is "not clear whether screening does more good than harm." According to Dr. Donald Berry, head of biostatistics at the M.D. Anderson Cancer Center, if the data is read carefully, the benefit for women 40-50 is really only 9 percent, which is not statistically significant, meaning it could represent the play of chance and not a real advantage. The recommendation not to begin mammography until age 50 has to do with medical issues, more than cost effectiveness issues. Mammography is not harmless. You are subjecting 1,899 women to annual doses of ionizing radiation to the breasts, with some unavoidable scatter to chest wall and lungs. We do not know how many women who are irradiated by mammography in their 40s will develop radiation-induced breast cancer (or even lung cancer) in their 60s, 70s, and 80s. The other problem is that women in their 40s tend to have very dense breasts, making it more difficult to get an accurate exam. These women often are called back for "additional views," giving them even more radiation. There are more false positives, leading to breast biopsies and sometimes unnecessary lumpectomies, in cases where the biopsies are technically suboptimal. In contrast, in older women, their breasts are less dense, making the examination more accurate, with fewer false positives, and there are fewer years of remaining life to develop a radiation-induced malignancy. I would not want to see the "politics" of the American Cancer Society trump over "science." I would wish the PA Breast Cancer Coalition would do likewise.